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The Role Your Vaginal Flora Plays in a Healthy Microbiome | Dr. Caroline Mitchell


The Role Your Vaginal Flora Plays in a Healthy Microbiome with Dr Caroline Mitchell

In this episode, we take an in-depth look at the delicate balance of the vaginal microbiome. Dr. Caroline Mitchell, distinguished reproductive health researcher and faculty member at the Vincent Center for Reproductive Biology at Massachusetts General Hospital, shares her profound insight on why a healthy vaginal microbiome is crucial in women's health. 


With a background in Women’s Studies at Harvard College and groundbreaking research funded by prestigious organizations, Dr. Mitchell brings a wealth of knowledge and experience to the discussion. She explains the complexities of understanding vaginal flora, the challenges posed by bacterial vaginosis (BV), and the intriguing connections between gut health and vaginal health. 


Listen to learn about some of the most significant yet overlooked aspects of women's reproductive health. We discuss how to balance the vaginal microbiome, what to do about chronic bacterial vaginosis, use cases for a vaginal microbiome transplant, and what innovative treatments are emerging in women’s health. 



Key Discussion Points about the Vagihnal Flora

  • Why a healthy vaginal microbiome is crucial for women's overall health and how imbalances can lead to conditions such as bacterial vaginosis (BV).

  • The difficulties of limited funding and the complexity of research regarding the vaginal microbiome.

  • Symptoms of BV, its limited treatment options, and common misdiagnoses such as vulvodynia.

  • Yeast infection vs. BV vs. UTI symptoms.

  • The impact of antibiotic use on the vaginal and gut microbiomes, plus the need for caution and further research.

  • Vaginal microbiome transplants and the potential of lactobacillus crispatus in treating BV, plus the future of an at-home vaginal microbiome test.

  • What to consider when looking for the best women's probiotics for vaginal health, and how to avoid unnecessary products and irritants.

  • The importance of accurate diagnosis, treatment, and management for vaginal health.


"When the good kind of lactobacillus are not dominating the vaginal microbial community, people are at higher risk for preterm birth, HIV acquisition, human papillomavirus—at risk for both acquisition and progression to cervical dysplasia and potentially cancer."

 - Dr. Caroline Mitchell



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Transcript

Today we have the privilege of speaking with Doctor Caroline Mitchell, a pioneer in the exploration of the vaginal microbiome. Are you experiencing persistent issues like bacterial vaginosis, yeast infections or unexplained discomfort in the vulvovaginal area which some of us refer to as down there. You're not alone and there may be more to it than you realize. These symptoms can often be traced back to an imbalance in the vaginal microbiome, a crucial but frequently overlooked component of our health. Doctor Mitchell joins us to unravel the mysteries of the vaginal microbiome explaining how this delicate ecosystem within our bodies influences not just our reproductive health, but our overall well-being. We'll delve into the signs of imbalance, the implications for our health and what we can do to restore harmony.


Get ready for an enlightening conversation that bridges the gap between scientific discovery and the experiences of women everywhere. Let's welcome doctor Mitchell to Fempower Health and start the journey towards understanding and empowerment.


Doctor Mitchell, it is so nice to have you on Fempower Health. I learned about you when I read Rachel Gross's book on, vagina obscura, and I saw, so much great information from you about trials that you're conducting on the vaginal microbiome and some really interesting stats. And the microbiome is a fairly popular topic on Fempower Health. And so I wanted to speak straight with you, the expert and researcher on this topic, and share information that that we as women need to know and may not know, and, honestly, the industry may not know. So based on the lack of research, of course. So before we dive in, I'd love for you to give your background and, why you're so passionate about this topic.


Sure. Thanks for having me. People who know me know I will talk about vagina stuff anytime, anywhere. So here I am. I, was a women's studies major in undergrad before it was called gender studies, and I think that is where I first became passionate about advocating for women once I became an OB GYN for women's health. I went into my residency not really knowing what I wanted to do, but thinking I wanted to do global health and HIV prevention. And my chair of my department where I did residency said, you know, if you really wanna make a difference, you should understand more about the lab and about the basic science, and you should learn about the vaginal microbiome, which turned out to be the best advice I've gotten, in my career. And so that's where it all began.


And then my clinical practice really followed my research interests.


You know, it's funny when you said women's studies. I went to the University of Florida, and that was quite frankly my absolute favorite class by far. I mean, because I was a chemistry major, so it was so different and so fascinating. And, I have to say that the teachers were very difficult. I heard they did not give a lot of good grades, and I always aced the exams. And I remember, I think for that class, I had to write, like, 5 papers, and I think I did it all in one night. And it was the most fun ever. So I fondly remember.


And I think my fascination with women's health actually came when the FDA mandated women are taking clinical trials. I wrote a paper on it, forgot about it, and found it about 10 years ago. So, yeah, it's amazing where where these different things that happen in the world and in our lives take us. So I'm really glad that this took you to the direction that it did. I would love for you to talk about the vaginal microbiome and the role it has in our overall health. And I wanna pull I have a lot of quotes, well, a few, from Vagina Obscura, because that was my my source of some of your thinking, is we don't understand what makes a healthy vagina at all. So that is a little bit scary. So can you expand on that statement plus what we should know?


Many people will say, like, what is the microbiome? And that is just the bacteria and viruses and fungi, but mostly, we mean bacteria living in and on us that we really should think about as almost another organ system, but as as a group of organisms that contribute to our function and our well-being. So the vaginal microbiome does that for us in the reproductive tract. What is fascinating about humans, we are the only species that have the particular sort of type of community that we associate with vaginal health, which is lactobacillus dominating the community. No other animal species has anything like it.


Why do you think that is?


It must be I mean, evolution would be the easy answer. Yeah. Complicated answer because what about it? We don't really know, but it means there's no animal model in which to study things. So we know what a healthy vaginal microbial community looks like, but why does one person have that and another person doesn't? Is there a particular type of good bacteria that's good for all people, or is it does it depend on other parts of your background? Does it depend on your environment? What goes into deciding or or determining what bacteria you have? We don't know that. And it's very challenging to model because we don't have that sort of controllable system. We have to look at people, and people are complicated.


If I remember correctly, the data's also showing that depending on your ethnicity. Correct? Race, ethnicity, I don't know all the nuances of the factors. There's also different degrees of what normal is, so to speak. There are nuances where there seems to be commonalities depending on your ethnicity. Is that is that true?


That is that is true in terms of the prevalence of different types of communities, of microbial communities in people who self identify as black or self identify as Hispanic compared to folks who identify as white. I think what is always important to remember is that race is not a genetic thing. Ethnicity is not a genetic thing. And so it is probably some contribution of environment, lived experience, something else that's con something that we're not measuring that is sort of a that ethnicity or race is a proxy for, that is what is contributing to the microbial composition, and we don't know what that thing is.


Oh, that's so scary. So given there's so much that we don't fully know, why is it so important to have a healthy vaginal microbiome? Like, what does it do for our overall health?


So there's two levels of answer to that question. There's the individual level, which is often when people have a shift or a change or a different pattern in the vaginal microbial community, they have symptoms, and they don't feel as well. And it's very disruptive to people's sexual health, their general daily well-being. So that's one level. The second level of answer is that when there are not the good kind of lactobacillus dominating the vaginal microbial community, people are at higher risk for preterm birth, at higher risk for HIV acquisition, at higher risk for human papillomavirus, both acquisition and then progression to cervical dysplasia and potentially cancer. So, again, this this community that lives with us and is sort of helping us along, if it's not in the most optimal configuration, it may not help protect us from these things.


And I believe there's 2 quotes that I wanna say here based on what you just, shared. So one was about women with BV specifically. They have double the data you just you just said, and you mentioned that this is how we sell it as being important. Because women's quality of life, women's sexual health, women's symptoms are not usually compelling enough. They're just vagina problems. Wow. So, you know, we talk a lot about yeast infections and UTI and BV. And when I did research on the vaginal microbiome and when I think about the women that have come to me about their different challenges, What was interesting is bacterial vaginosis really rose


to the top as far as a big challenge in solving for the vaginal microbiome. But I also hear women coming to me with issues with recurrent yeast infections and UTIs. How much does the vaginal is is it all the vaginal microbiome, or do we not know yet? So for recurrent UTI, which I'll start with, there is probably some component of the vaginal microbiome. There are especially after menopause. Because after menopause, the many people have fewer or almost no lactobacillus, and then you will see correspondingly more e coli, which is one of the most common causes of recurrent UTI. So in many cases, I think recurrent UTI, the vaginal microbiome contributes to recurrent UTI. It may not be the whole thing, and there is a a very large literature on recurrent UTI that I am not an expert in, but, I would say the vaginal microbiome plays a part. For yeast, yeast is fascinating because in the lab, lactobacillus will kill Candida, will kill yeast.


In the lab, lactobacillus will control yeast and keep them from forming the sort of branching hyphae that we see under the microscope and that probably are associated with causing a lot of the symptoms. However, in people, when we see people with vulvovaginal candidiasis, so like a yeast infection causing symptoms and irritation, most often, they have a lactobacillus dominant vaginal bacterial community. It's this huge paradox. So there's something we're missing in between. I don't know if it's you need the right lactobacillus or what is going on, but this idea that I'm gonna use a probiotic to prevent yeast infection, or I'm gonna eat yogurt, or I'm gonna put yogurt in my vagina, At least based on what we see in people, that's not gonna work.


I just wanna jump into the research part of this because, you know, trying to understand a lot of these things. I mean, you're even doing research, and it's been difficult to get funding. I mean, I know that I've been really closely monitoring all different aspects of women's health, and it's really clear that unless there is, you know, we lack enough public policy. Right? So at this point, it's really been if a company is interested in developing a product, they need to better understand said condition to develop and market said product. Like that's a lot of it. Right? Or, you know, academic medical centers who may simply be interested hard to do this research. So I'd love for you to just expand a little bit on that, and then I'd love to dive into some of, these other conditions as well.


I think one thing about funding you're right. So pharma often either of these, because there's a huge half of the market is women. Right? Bacterial vaginosis is present in about a quarter of women. 75% of women will have a yeast infection at some point in their lives. So it is a huge market share. And the fact that treatments are bad and no one is really from pharma is really working on a solution, one could hypothesize as a scientist that possibly because many people who lead pharma companies are men, that it doesn't seem like a priority. Pharma and pharma has a lot more money than the government or academics or even many philanthropists. I think the NIH, often, the science needs to be complicated and fancy and cutting edge.


And because the human vagina doesn't have an animal model, it's hard to do things like knock out a gene or, like, do these very meticulous basic science studies that people are accustomed to seeing for things like cancer or cardiovascular or diabetes, all of these things that have model systems where you can pick apart 1 at a time the things that contribute to what's going on, which is really beautiful and elegant science, and we have not been able to do. Our research often has to involve people, and people are complicated. And so it's, I think, a little bit harder sell, and it's women's health. And this question of, like, should I fund cancer, or I should I fund vaginal discharge? And it sounds like a very easy choice, but until you meet people who have recurrent vaginal discharge, for whom this is debilitating and ruining their lives for years, and no one can help them, and they get blown off by the medical system. And I see those people in my clinic, and it is a big problem.


So talk to me then about bacterial vaginosis, because that was even where Rachel Gross started her book, and I had the pleasure of interviewing her as well. And, we made it just a fun one because you have to read the book. I mean, it's so we just kinda chatted about some of the fun facts that, that she came up with in her years of doing the research. But, you know, she came upon, you through that, writing that book. So tell us about bacterial vaginosis and the research that you're doing as well. Well. So let's start with what it is.


So bacterial vaginosis is a syndrome, which means we there's not one individual cause. It's not like the flu, which is a clear infection. BV is a syndrome. So we, diagnose BV by looking and seeing our lactobacillus there, and they are not there in BV. And then we see this community of other types of bacteria that sort of overgrow and are many more in number and type than we would see in the most optimal community. The pH rises because there are no lactobacillus to make the lactic acid and keep the pH low, and then people end up, in many cases, with a discharge and an odor, although about half of people with BV have no symptoms at all.


What is the cost to not knowing you have BV?


At this point, all we know is associations, but it is associated with cervical dysplasia, risk for preterm birth, maybe risk for infertility, and risk for acquisition of other infections. Studies around the world show these associations no matter what population you're in. It's a very consistent pattern that we see. So what can people do about it, and what are some of these stories that you're hearing from women just to kinda bring to light what you're seeing directly? The first line treatment for bacterial vaginosis. In many people, it works well at first, but at 1 month, there's about a somewhere between 30 to 60% recurrence of BV. And the say the 2 antibiotic classes that we recommend right now are the same 2 that were recommended with the 1st CDC treatment guidelines in 1982. So there's, like, different flavors of them, but they're the same two categories of antibiotic. And you will see people who say it goes away for a couple months and then it comes back, or it goes away and then as soon as I have sex, it comes back, or as soon as I get my period, it comes back.


And at some point, many people find their providers run out of options for treatment and give up. And so the patients don't even come in anymore. They suffer at home, or they use over the counter remedies, or they try different things that they find in support groups on the Internet. And so I think part of it is because it's a syndrome. We don't have a clear cause, so it's hard to know exactly what should we change about our treatment. And that's sort of what we're trying to figure out is how do we antibiotics work reasonably well in most cases to get to decrease BV or to make it go away temporarily, but how do we keep it from coming back? And that's where our studies, where we're trying to intervene.


1st with antibiotics. I hear so much about we need to limit how often we take them over the course of our lifetime. Like, if these women are taking it and there's this 30 to 60% recurrence and if they have to take courses over and over again. I mean, I know are are we literally having to weigh potentially impacting our gut health and could repeated antibiotic use make this a long term harder to solve problem.


I mean, this is why for BV, the recommendations, you say you can use oral or vaginal antibiotics because they all work about the same. But, generally, for BV, I prescribe vaginal antibiotics for exactly that reason is I don't wanna impact the gut microbiome if I don't have to because that is critical for many other parts of our health. We don't really know how much of a connection there is between the gut microbiome and the vaginal microbiome.


The the dominant so the the fancy new molecular sequencing that has sort of opened up the world of the microbiome is best at describing things that are there in abundance. So the individual, like, in the in the vagina, we have mostly lactobacillus, tons and tons of lactobacillus. And if you think about, like, a a glass jar full of white marbles, if there's 2 little blue marbles in there, we're probably not gonna find them. And that's true in the gut, and that's true in the vagina. And I think for the gut, any vaginal types of bacteria are the blue marbles, and in the vagina, it's the reverse. And so the technology we're using now to study the microbiome doesn't really allow us to see the connections well. So I think we have to to, develop technology that allows us to see those those bacteria that are present in small abundance in one area that might be very important for the other, and that will allow us to understand the connection better, but just hasn't been done yet.


What about women who are having because when I think of the word syndrome, like, I I interviewed someone on genitourinary syndrome of menopause. And, just thinking about how that was described, UTIs and yeast infections and things like that, could though the recurrence of that also be attributable to BV? Like, is BV like an umbrella term of all of that, or are these separate and unique? And does it even really matter if how we work through the pillars of yeast infections, UTIs, BV, and anything else?


They are different. I will say people with recurrent BV who get treated over and over with antibiotics often end up with a yeast infection, so then you end up with both. But it's because of the antibiotics you got for the BV, not because of the BV itself. And in terms of whether BV increases your risk for recurrent UTI, there's actually not a huge literature, out there. So it seems plausible, but it's not a robust like, it's not a, because you have recurrent BV, you're absolutely gonna have recurrent UTIs. That doesn't seem to happen clinically. So I think they are separate.


Is the syndrome more we don't understand enough about BV and so we have to for now?


So it's more actually the it's not the constellation of symptoms. It's the constellation of bacteria. So often a bacteria that people hear about a lot with BV is Gardnerella vaginalis. There's another one called adipopium. There's one called megasphera, and there's one that no one's been able to grow, so it doesn't have a fancy name. It's just BVAB 1. Okay. And some people, when they have BV, have lots of gardenorella and a little bit of the other ones.


Some people have lots of Megasphaera and a little bit of the other ones. Some people have equal numbers of all of those. And all of that is BV, but you can imagine that not all antibiotics might work the same because it's different bacteria. And that there's sort of a wealth of questions there, and it's it is hard to answer without that model system where you can, like, change one thing at a time.


Treatments outside of the antibiotics. So there's the boric acid, maybe a couple of other things, but I'm also thinking of naturopathic doctors and if you've seen things that they're trying to do and any caution that you would like to give to women.


The things I worry about when people try things for vaginal health is just not causing irritation. That sort of my because many things, it might work. I agree. Like, there's plenty of things. We clearly don't have great answers in medicine. So, like, there's plenty of places we could look for more answers. Things like tea tree oil, which some people use, is pretty caustic, and so, like, that, I would advise against that. Things like garlic, it's fascinating.


Again, in the lab, garlic totally the compound in garlic, allicin, totally kills yeast. Totally. But you cannot put enough garlic cloves in your vagina to get sufficient levels of allicin to kill the yeast. Many things that people are trying have yes. There's, like, some science there, but the delivery method is what we need to work on. So I tend to tell people as long as it's not terribly extreme and as long as it's not causing irritation, I think it's pretty reasonable to try a lot of things. But I I do worry about putting too much stuff in the vagina that might disrupt healthy lactobacillus.


What about the boric acid treatment? Tell me because Rachel shared her story about that experience, but it still may be used. People may have different experiences with it. I'd love for you to just share in case people run across that as an option.


The fact that what the second or third line then that I do recommend to people is a poison is, painful to me. Yeah. However, it works very well for some people, and that's what we have. The point could be made that coumadin was based on rat poison, so poisons can be used in health. Feel like we could do a little better.


Let's talk about your research on vaginal flora and BV.


The first study that we're doing is, vaginal microbiome transplant, which is taking a healthy community of bacteria from vaginal fluid from a healthy donor and transplanting that into someone with recurrent BV after that course of antibiotics to try and put in a healthy community that hopefully would then prevent recurrent BV. That was first piloted by, an investigator in Israel, Dr. Lev-Sagie. Her study did not have a was not randomized. It was sort of a case series. So ours is a randomized trial, and super excited. It's funded by the NIH, and everyone in clinic tells me, I'll do anything to get rid of my BV. And I tell them about this, and they say, maybe not that, which is fascinating to me. People are absolutely right to be concerned about material from other human beings.


However, we test our donors and the donations to the best of our ability for every infection we can think of, And so we think we're doing it as safely as it can be done.


How does the vaginal microbiome transplant work?


So we know that lactobacillus dominant. So having mostly lactobacillus is the best pattern, but it's not just lactobacillus. Lactobacillus may need friends to support it and keep it happy and keep the community stable. And what we don't know is who those friends are. And so the idea with transplant is just take all the stuff that's growing together and maybe some that we can't find with our fancy methods because there's just a couple of them, but they're metabolically single individual isolate like you might get in a probiotic. And the idea is we just don't know what the good stuff is. So let's put all of it in and then figure it out on the back end, which one of these work the best, and those must have the best stuff.


Just for clarification because of the way you said it now, we can be pretty clear that no matter how much lactobacillus we try to take, if we have BV, it's the something else that making it not grow that is probably causing an issue. So no matter how much we try to put in, it seems to not work. So therefore, we probably is that?


I would say no because the other study we're running Okay. Takes the absolute opposite approach as transplant. Okay. Which tells you we really so transplant is the the premise is we don't really know what the good stuff is. Let's just put it all in and figure it out. The other study we're doing, which is funded by the Bill and Melinda Gates Foundation and is a labor of many, many different scientists in a group called the Vaginal Microbiome Research Consortium says we know exactly what the good stuff is. It's this particular lactobacillus called lactobacillus crispatus. And there are many different kinds of strains, so individual types of crispatus.


And maybe it's just that that some people need one strain, some people need another strain. So let's make a product with a bunch of strains so it's relevant to more people. And so in that study, we're doing we're studying 1. It's called a live biotherapeutic instead of a probiotic because we're putting it through the FDA approval process to as if a prescription medication. So it's being held to a very high standard. One has 6 strains, and one has 15 strains. And we're studying that here in the US and also in South Africa.


How far along are you in the trial via the Vaginal Microbiome Research Consortium?


Both sites have enrolled their first couple participants, which is and this is a this this research group made this medication, so they're the first people in the world to try this medication, which is really cool. And so we'll see. But we hope to finish the study by the end of this year and have results early 2025.


Are you still looking to enroll patients?


Absolutely.


Are you worried that if people find out about both, none of them are gonna wanna do the transplant? Because I think both studies are important.


We can't guarantee that the product is going to help, and so we really need good Samaritan, so to speak.


I would say so the the the subtext or the, like, asterisk for the, live biotherapeutics study is because it's a first in human study, and we wanna make it sort of as easy for the product as possible. We're asking people to be on, oral contraceptives or that for many people, people with an IUD, people with Nexplanon, or people who don't sort of do well on hormonal contraceptives, those people could be in the transplant study.


What else do you know is being looked at for the vaginal microbiome that maybe your group isn't doing that we should know about?


Lots of things. So there is a company, a well established company that has been doing work with a lactobacillus crispatus live biotherapeutic for a long time, called Osel. They have a single strain of lactobacillus crispatus, so the best kind of lactobacillus in just a single strain. They conducted a trial in the US, that showed a benefit, a reduction in recurrent BV with that product, after antibiotic therapy. And just this week, we presented results from a study in South Africa with that same product showing similarly a benefit in colonization with the lactobacillus crispatus. So the live biotherapeutic, which is, again, like a probiotic, but holding it to the same strict FDA standard as a medication, that I think is a good future direction, and, there will be more products coming. There is a company called Freya Bio Sciences that is also working on vaginal microbiome transplant. And so I think we'll be hearing from them, and they do theirs a little bit different than ours, and I think together, the results are gonna be a little fascinating.


And then there are people working on so we see sometimes in some people, there is antibiotic resistance. So antibiotics don't get rid of the BV. And in that case, we need something better than antibiotics, sort of, to get rid of the the BV associated bacteria. So there's a company, BioNTech, working on product that targets gardenorella vaginalis. There are other folks working on products that target there's an idea that there's a biofilm in BV, which I confess I don't I'm not part of the folks who believe there's a huge biofilm, but there are products that, sort of are trying to address that possibility. Then the question is, what about prebiotics? So to this idea that maybe lactobacillus need a little bit of support. Maybe they need something to make the environment more hospitable. So a product that contains both some good lactobacillus and some helpful stuff.

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What is the helpful stuff? We don't yet know. So those are on the mark are in development. I will say the thing that many people talk about. They come to clinic and they say, I need to fix my pH. I'm gonna fix my pH, and then everything will be better. Sadly, it's not you can't do that from the outside in. There's this big study called the VITA study in the UK that compared vaginal lactic acid based product for treatment of BV to antibiotics, and it stopped early because the antibiotics were so much better.


The low pH happens when lactobacillus are there making lactic acid to lower the pH. So it's from the inside out.


Your product that you're working on with the Bill and Melinda Gates Foundation, so we talked earlier about how if, you know, pharma who has the money or others are interested funding it. So let's say the trials go well. What are the next steps? Would it be trying to find a manufacturing company to potentially sell it to for them, okay, to market?


It would. And one of the requirements, for any foundation funding is what's called a compassionate license. So anyone who decides to market to develop and market this type of product that's developed through funding with the foundation, it needs to be available to low and middle income countries at a in a way that's affordable.


That is awesome. Another question that, I meant to ask earlier, but we had so many cool things to talk about with, these different conditions is the at home tests. You know, there's a lot of things in women's health where we have a diagnostic and not a treatment, a treatment, not a diagnostic, and then probably a 1000000 scenarios in between. So we have products that that do test for the vaginal microbiome at home. I would love to get your thoughts. Like, my initial is this is great. It's great for education. My question is always, so then what do we do? Because it sounds like there's a lot we need to learn.


I would love to get your, perspective. Because, again, I'm all about innovation in women's health, but I also think it's important to know the the pros and cons of what's out there.


Right. I totally understand why these companies exist because providers blow people off. Because BV is hard, it's frustrating for providers not to know what to do. And so I think that gets communicated to patients sometimes. So I understand why the companies exist. I also worry that they may not be able to detect all the things that might be going on. Could be gonorrhea and chlamydia. Like, it could be an STI, this type of symptom.


And I don't I don't know if the commercial assays pick all of that up. There are some things you can only see under the microscope, and, admittedly, many providers don't look in the microscope either. So it may not be any better going to an office. And I would say I looked at the website, for one of these, and they reference as do many commercial tests, commercial assays, a couple of conditions that I think are not as well supported by the science, so something called cytolytic vaginitis, something called aerobic vaginitis. Often, they'll also talk about the mycoplasmas and urea plasmas, all of which I understand why people want a term to call these things because there's so much we don't understand. But to me, the science does not support them as separate entities. And so if you tell someone, oh, you have aerobic vaginitis, not really any different treatment recommendation. There's nothing to do.


I don't think cytolytic vaginitis is really a clinical entity. So if you're told you have that, then it gives you a problem that, again, there's not a lot to do. Although I think these companies also offer some products, which might be fine, but I I just I find it I understand there is a vacuum. There is a vacuum that they are filling, and people need something and they need solutions. So that's why we're trying to provide science and science based solutions.


One of the things that I'm also fascinated by with all these companies is the data they're collecting, Whatever success they may have on the back end for the treatment and the the forefront, they're at least collecting data and, you know, for business reasons, may be able to sell that data. Obviously, I'm sure they would sell it as de identified so people's, personal information doesn't get out there. But it would be interesting to have these databases to understand just how many people have it and the combination of things, etcetera. One other question then, the at home test versus going into a doctor's office, because I know back when I mean, it's so funny how much women's health has changed. Like, when the at home test really started, it was the the, hormone tests for fertility. That's how it all began. And now it's really evolving. So for this, can you if anyone's asking, like, at home versus going to my doctor, I don't know if you have any perspectives on the way they're testing versus what would be done in a doctor's office.


I'm pausing because there is a recent paper out of the University of Pittsburgh suggesting that when people go to a doctor's office, they get treated inappropriately about 40% of the time. So I'm not I like the recommendation if people are using appropriate tests, which I think would be in a clinical setting for most clinicians, a molecular test that tests for trichomonas, Candida, and then BV using an algorithm looking at several of the different types of bacteria that could be present in BV. The commercial, you know, direct to consumer microbiome tests do some of the same that same work. Again, I don't know how much how well they distinguish Candida and Trichomonas, which, again, I sort of my feeling is we should be testing for at least those three things when people come in. So, that I don't actually know the answer to. So that's why I would prefer office, but I would prefer an office that use these molecular tests, or me with my very fancy microscope that I love dearly and will never let go of.


I appreciate you sharing that because one of the things that I'm actually thinking of focusing a lot more on is given all these wonderful experts I get to interview. At the end of the day, what do we do in the meantime? What are the tips of how if I'm a woman and I have these symptoms, what do I go talk to my doctor about? What do I make sure that they do? Because they're busy and may forget, or maybe I didn't say the right thing to trigger them to do x y z test because it's a 10 minute appointment. So this is actually very, very helpful. Anything else that you would want women or clinicians to know based on what we know in the meantime? How should we look at vaginal microbiome health, BV?


I would say couple things. So one is that oral probiotics are probably a waste of money for your vagina. Not for your gut, but for your vagina. Vaginally delivered probiotics, over the counter probiotics are probably a better approach, and they should have this lactobacillus crispatus in them. And people should know they're not held to the same standard as a medication. So I don't know if they're the same as what Osel actually tested. But given the success of the Osel product, it's probably reasonable to use a vaginal lactobacillus crispatus product. The second thing that I feel very strongly about is I so often see people in my clinic who say, I have recurrent BV.


And what are your symptoms? And they say pain and burning. In general, that is not BV. It is actually more likely a pain condition called vulvodynia. And for vulvodynia, people tend to see 3 to 5, on average, 3 to 5 physicians or providers before they get a diagnosis. And so this is the other thing. If you are being treated for something over and over and over and it's really not working, it's probably not that thing. Usually for BV or yeast, something will work a little bit and then come back. And if it's not working at all, the we need to question the diagnosis.


So that that, I would say, there are some things that, even if a test is saying, oh, it's BV, our tests are not perfect, and so it may be something else. That's the second thing is, like, if you feel like things aren't working, rethink the diagnosis. And then number 3 is that, you probably, in most cases, do not need a product, a special product, anything for the vagina if you're not having symptoms. Just going about your daily life and actually using less stuff on the vulva and vagina is the best thing you can do for your vulvar skin and your vaginal microbiome health.


Including probably not wearing underwear at night is what I hear a lot of doctors say. And and I I have to ask, is there anything else I haven't asked you that you're like, we need to talk about this? Because some of the questions I asked, I had not planned on asking at all.


No. The the thing I feel most strongly about is the the vulvodynia because I see so many people who've been treated for a long time for an infection they never had.


I just published a blog post that summarized my conversation with Dr. Jill Krapf, and I know she suggested ISSWSH, which has a list of a lot of the sexual health experts who treat this condition. And so I would suggest for anyone who, is struggling that's trying to figure out how to find a doctor. I also have as I do these interviews, I find out about all these subspecialists and tools to find an expert, so they're all on my website. If you just go to find a doctor, whatever you're you've got, if it exists, I probably have it, so check it out. But thank you. This was truly wonderful, and it's been an honor. I'm so happy that you're doing this research and and have been led to the path that you're on.


Thanks so much for your interest as I could talk about this forever, but we'll keep it to this.


Guest Bio

Dr. Caroline Mitchell, a distinguished faculty member at the Vincent Center for Reproductive Biology at Massachusetts General Hospital (MGH) in Boston, has a remarkable career that bridges clinical practice with groundbreaking research. After earning her BA in Women's Studies from Harvard College and serving in the Peace Corps in Southern Africa, she returned to Harvard Medical School for her MD, followed by OB/Gyn residency and an MPH degree at the University of Washington in Seattle. At MGH since 2014, Dr. Mitchell dedicates her research to understanding the vaginal microbiota's role in reproductive health, supported by prestigious grants from organizations like NIH, the Doris Duke Foundation, and the Bill and Melinda Gates Foundation. As the Director of the Vulvovaginal Disorders Program and chair of the OB/Gyn Diversity, Equity, and Inclusion Committee at MGH, her clinical and research work includes pioneering the first randomized trial of vaginal fluid transplant for recurrent infections and investigating novel vaginal biotherapeutics, underlining her commitment to advancing women's health globally.


Disclaimer

The information shared by Fempower Health is not medical advice but for informational purposes to enable you to have more effective conversations with your doctor.  Always talk to your doctor before making health-related decisions. Additionally, the views expressed by the Fempower Health podcast guests are their own and their appearance on the program does not imply an endorsement of them or any entity they represent.


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